Download Hand Deformities, Fractures, and palsy

Hand Deformities, Fractures,
and palsy
By Adnan AL-Maaitah
Medical ppt http://hastaneciyiz.blogspot.com
NOTE
• The following subjects are NOT mentioned in the guidelines
– Dupuytren contracture (slides 28-31)
– Hand fractures (32-45)
– Hand palsy (46-57)
• Sry, but I got the guidelines after finishing the seminar 
-Mallet deformity
-Trigger Finger
-Boutonniere Deformity
-Swan – Neck deformity
-Dupuytren contracture
Mallet Finger
• Aka: baseball finger
• Deformity in which the
fingertip is curled in and
cannot straighten itself
• Due to injury to
extensor digitorium
tendons at DIPJ
Mallet Finger/Causes
Forced flexion of the finger
when finger is extended:
. Sport Injury: Finger struck by
volleyball, basketball or
baseball when it is in
extension
. Other common mechanisms
of injury include forcefully
tucking in a bedspread or
slipcover or pushing off a
sock with extended fingers.
Mallet Finger/Presentation
• After DIPJ forced flexion: inability to actively extend the distal
joint, intact full passive extension
• Often injury is painless or nearly painless
• Dorsum of joint may be slightly tender and swollen
• Order X-ray to make sure there are no fractures
Despite active extension effort, the distal
interphalangeal joint of the index finger rests
in flexion, characteristic of a mallet finger
This x-ray depicts a large, dorsal-lip avulsion
fracture from the distal phalanx, a bony
mallet injury.
Mallet Finger/Managment
• Mallet finger splint (610 weeks)
• Surgery:
– In case of volar
sublaxation of distal
phalanx or avulsion
fracture
– K-wire (Kirschner wire)
Anteroposterior radiographic view of finger after 4
weeks. The longitudinal K-wire is blocking the distal
interphalangeal joint from flexion to protect the repair
Trigger Finger
• Trigger finger is the
popular name of
stenosing tenosynovitis,
a painful condition in
which a finger or thumb
locks when it is bent
(flexed) or straightened
(extended).
Trigger Tension
• Due to narrowing of the sheath that surrounds the tendon in
the affected finger, or a nodule forms on the tendon.
• Trigger finger is often an overuse injury because of repetitive
or frequent movement of the fingers (ex. hobbies as playing a
musical instrument or crocheting)
• Trigger finger may also result from trauma or accident
• It is called trigger finger because when the finger unlocks, it
pops back suddenly, as if releasing a trigger on a gun.
Trigger Tension
• Clinical Picture:
– Affected digits may become painful to straighten once
bent
– May make a soft crackling sound when moved.
– It props back suddenly when straightened
– Symptoms are usually worse in the morning and improve
during the day
• Treatment:
– local steroid injections and splinting (weeks to months)
– Surgery: cut the sheath that is restricting the tendon.
Trigger Tension
Introduction of the needle into
the tendon sheath at 45° to the
palm for injection treatment.
Boutonniere Deformity
• Aka: Buttonhole
Deformity
• Hyperflexion at the PIP
joint with
hyperextension at the
DIP
• Passive extension of the
PIP joint is easy.
Boutonniere Deformity
Boutonniere Deformity
• Flexion deformity of the PIP
joint, due to interruption of
the central slip of the
extensor tendon:
– The lateral bands separate
– The head of the proximal
phalanx pops through the gap
like a finger through a button
hole
– The DIP joint is drawn into
hyperextension.
Central Slip
Lateral Band
Boutonniere Deformity
• The 3 main etiologies:
– RA and other inflammatory arthritides (most often)
– mechanical trauma
– burns and infections
• An X-ray should be done to detect avulsion fractures
Boutonniere Deformity
• BD in patients with RA can be classified into 1 of the following 3 stages,
which serve as a guide to the appropriate management:
– Stage I (mild) is the earliest stage and is the result of PIP joint synovitis
with mild extensor lag that still can be corrected passively. The
metacarpophalangeal (MP) joint usually is normal, and the DIP may or
may not be hyperextended.
– Stage II (moderate) is characterized by 30-40° of flexion contracture at
the PIP joint and hyperextension of the MP joint as a compensatory
mechanism. The finger has increased functional loss. Early passive
extension still is possible. With time, soft-tissue contractures develop,
and passive extension becomes restricted.
– Stage III (severe) begins when the PIP joint can no longer be extended
passively. Radiographs demonstrate destruction of the joint surfaces
Boutonniere Deformity
Treatment:
• Splinting 4 weeks minimal (6 weeks preferable):
– safety-pin splint (<40 degree)
– Dynamic spring splints (> 40)
• Surgery: When the deformity is the result of a dislocation of
the PIP joint
• Surgery carries a relatively high risk of FAILURE to achieve
completely normal functioning extension mechanism of the
finger.
Bunnell Safety Pin Finger
Splint
Dynamic spring
extension splint
Swan-Neck deformity
• -the PIP joint is hyper
extended . DIP joint is
flexed.
• Cause:
– Volar plate becomes
weak -> hyperextension
of PIPJ -> flextion of DIFJ
• Due to injury or
inflammation (RA)
Swan-Neck deformity
Swan-Neck deformity
• Swelling and pain due to inflammation from injury or disease (RA)
• X-ray is done to evaluate the joints (RA) and look for fractures.
• Treatment:
– A boutonnière deformity caused by an extensor tendon injury can
usually be corrected with a splint (Murphy Ring Splints) that keeps the
middle joint fully extended for 6 weeks
– When splinting is ineffective, surgery may be needed.
MURPHY RING SPLINTS
Dupuytren contracture
• Pathologic condition of
the hand in which the
fascia of the palm are
shortened and
thickened
• Common in south
europe
Dupuytren contracture
Dupuytren contracture
• Dupuytren's contracture is more common among people with
diabetes, alcoholism, or epilepsy
• The disorder affects both hands in 50% of people
• The disorder is occasionally associated with other disorders:
– Garrod's pads: thickening of fibrous tissue above the
knuckles
– Penile fibromatosis: shrinking of fascia inside the penis
that leads to deviated and painful erections
– Plantar fibromatosis: nodules on the soles of the feet
Dupuytren contracture
• Symptoms:
– The first symptom is usually a tender nodule in the palm
– Gradually, the fingers begin to curl.
– Eventually, the curling worsens, and the hand can become
arched (clawlike)
• Treatment:
– Surgery to correct contracted (clawed) fingers
Hand Fractures/Hx
•
•
•
•
Hand trauma, industrial
Hand dominance
Hand injured
Mechanism of injury:
– Clean/dirty environment
– Position of the hand
– Thermal, electric or chemical injury
– Wearing jewelry on finger, removed
• In assault:
– Hand open or fist clenched
– Lacerations (tendon injury)
– Contact with mouth, teeth
• Years since last tetanus immunization (esp. in lacerations and abrasions)
Hand Fractures/ P/E
• Hand examination:
– Compare with uninjured
– Signs of inflammation, abrasions, erosions
– Abnormal position (esp. fingers): rotational deformity
– Location of injury
– Capillary refill
• Neurology: radian, median and ulnar nerve
With fingers flexed at the metacarpophalangeal
and proximal interphalangeal joints and
extended at the distal interphalangeal joints,
fingers should all point toward the scaphoid
bone
Examination of the patient's hand with the
fingers flexed may clearly reveal a rotational
deformity
Hand Fractures
• Imaging:
– X-ray: AP, lateral and oblique view
– MRI, CT, Bone scan seldom needed
• ED care:
– Pain management, reduction, splinting, referral
– Primary concern is preservation of function
– Except for distal phalanx fracture, all pts. Should be referred to a hand
surgeon
Boxer’s Fracture
• A break in one or more
metacarpal bones,
usually the fourth or
the fifth, caused by
punching a hard object.
Such a fracture is often
distal, angulated, and
impacted
• Finger shorten
posteriorly
Fourth and fifth
metacarpal fractures,
oblique view
Scaphoid Fracture
• Epidemiology
– common in young men;
not common in children
or in patients beyond
middle age
• Mechanism
– FOOSH resulting most
commonly in a
transverse fracture
through the waist
(middle) of the scaphoid
Scaphoid fracture in the middle third
or waist
Scaphoid Fracture
• Clinical Features:
– pain on wrist movement
– tenderness in scaphoid region (anatomical "snuff box")
– usually undisplaced
• Investigations:
– x-ray (AP/lat/scaphoid views with wrist exended and ulnar deviation)
– +/- bone scan and CT scan
• Note: a fracture may not be radiologically evident up to 2 weeks after
acute injury, so if a patient complains of wrist pain and has anatomical
snuff box tenderness but a negative x-ray, treat them as if they have a
scaphoid fracture and repeat x-ray 2 weeks later to rule out a fracture
• Treatment:
– Undisplaced: cast
– Displaced = open (or percutaneous) screw fixation
Colles’ and Smith Fracture
• Colles’ Fracture:
– Due to FOOSH
– > 40 yrs, female (esp. osteoperosis)
– Fx fragment: upward-dorsal angulation (fork-like appearance)
• Smith Fracture:
– Aka: reverse Colles’ fracture
– Falling on the back of a flexed hand
– Fx fragment: volar (palmar) displacment
Colles’ Fracture
Smith Fracture
Both Bones Fracture
(Radius & Ulna)
• FOOSH, direct blow
• Internal fixation by
plates and screws
• Complications:
– Compartment syndrome
– malunion
Anteroposterior radiograph of a
displaced, midshaft both-bone
forearm fracture in an adolescent
with a transitional growth plate
Ulnar nerve palsy
• This occurs due to
nerve compression at
the elbow (cubital
tunnel) or at the wrist
(Guyon's canal) (Ulnar
canal)
• Muscle weakness and
atrophy predominate
the clinical presentation
Ulnar nerve palsy/Causes
Cubital Tunnel Syndrome
Guyon's Canal Syndrome
• Frequent bending of the
elbow
• Leaning on the elbow,
resting it on an elbow, rest
during a long distance
drive or running machinery
may cause repetitive
pressure and irritation on
the nerve.
• A direct hit on the cubital
tunnel may damage the
ulnar nerve
• A cyst within the canal.
• Clotting of the ulnar artery.
• Fracture of the hamate
bone.
• Arthritis of the wrist bones
Ulnar nerve palsy/Causes
• Symptoms & signs:
– numbness and tingling in the ring and little finger and the sides and
back of the hand. At Guyon's Canal, sensory supply to the skin of the
back of the hand is spared.
– The hand may become weaker resulting in trouble opening bottles or
jars
– Clawing may occur in the ring and little fingers
– Froment's test: by asking the patient to hold a piece of paper
between their thumb and index finger (hence checking adductor
pollicis). In a patient with Ulnar nerve palsy the interphalangeal joint
of the thumb will flex to compensate
• Treatment:
– Nonsurgical therapy: elbow or wrist splints to limit mobility in addition
to an anti-inflammatory drug such as ibuprofen.
– Surgical decompression maybe required in some cases
Froment's test
Radial nerve palsy
• Aka:
– wrist drop
– Saturday night palsy
• Causes
– Caused by excessive compression of the radial nerve against a hard
surface in individuals insensitized by the intake of alcohol or sedatives
– Broken humerus
– lead poisoning
– Stab wounds to the chest at or below the clavicle. Damage the
posterior cord of the brachial plexus
• Symptoms:
– Wrist drop
– Occasionally, the back of the hand may lose feeling
Wrist Drop
Erb’s Palsy
• Aka:
– Waiter's tip deformity
– Erb-Duchenne Palsy
Erb’s Palsy
• Due to brachial plexus damage, by excessive lateral neck flexion away from
sholder:
– Forceps delivery
– Falling on the neck
• Leads to loss of the lateral rotators of the shoulder, arm flexors, and hand
extensor muscles.
• The position of the limb, under such conditions, is characteristic:
– the arm hangs by the side and is rotated medially;
– the forearm is extended and pronated.
– The hand is flexed
– The arm cannot be raised from the side; all power of flexion of the
elbow is lost, as is also supination of the forearm
Erb’s Palsy
• The three most common treatments from Erb's Palsy are:
– Nerve transfers (usually from the opposite leg),
– Sub Scapularis releases
– and Latissimus Dorsi Tendon Transfers.
• Although range of motion is recovered in many children under one year in
age, individuals who have not yet healed after this point will rarely gain
full function in their arm and may develop arthritis
Medical ppt http://hastaneciyiz.blogspot.com